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Influenza 2001
Medicare Health Plan Reimbursement Program
Adult Vaccine Administration Record
Influenza Vaccine
The doctor or clinic may use this form for the written documentation required for every dose of
vaccine, or they may record it on your medical record. They will record what vaccine was given,
when the vaccine was given, the address where the vaccine was given, the name of the company
that made the vaccine, the vaccine's special lot number, the name and title of the person who gave
the vaccine, and the document number.
Information about the person to receive vaccine (please print)
Name: (Last, First, MI)Birt date: Age:
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Street a4dress:
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city* � e State: ; Zip
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Check the source of vour healthcare from the following:
Medicare
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Blue Care 65
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Fallon Senior Plan
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First Seniority (Harvard Pilgrim Health Care)
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Secure Horizons (Tufts Health Plan for Seniors)
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Signature of person to receive vaccine, or thatperson's guardian '
X Date
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For Clinic/Office Use
Vaccine name: Date vaccine administered: �1
Injection site: . Date VIS given. d Date on VIS Cf
Vaccine manufacturer: Vaccine lot. number:
Name and title of vaccine administrator:
Clinic/office address:
NO. ANDOVER BOARD OF HEALTH
21 CHARLES STREET 10/01/2001
NORTH ANDOVER, MA 01845
Errolyn C. Hewett
Woodridge
lA Emerson Court
No. Andover, MA 01845
January 12, 1981
Planning Office of Urban Affairs
No. Andover Homes, Inc.
25 Union Street
Boston, MA 02108
Attention: Charleen Regan
This is to inform No. Andover. Homes, Inc., that on the weekend of
December 26, 27, 28, 1980 .the.pipes at the residence of IA Emerson
Court, managed by Niles Corporation, froze and flooded the said apart-
ment at that premises. The water saturated the wall-to-wall carpeting,
and damaged several other items in the apartment. I suspect that water
damaged the matting and subflooring. The carpeting has been damaged
and should be replaced.
In approximately one week the carpeting had slowly dried, but the
result of the flood left a musty mildew smell. This confirmed my
suspicion that the matting is rotting. I reported the problem caused
by this situation to Niles Corporation, Landlord's Duty Authorized.
Agent, Ellen Brawley on January 5, 1981.
No action has been taken to remove the damaged carpeting. Niles
Corporation and/or Andover Homes will be liable for not maintaining the
entire premises in a good tenantable condition.in compliance with all
applicable laws and regulations.
Sincerely,
1
C
Errolyn C. Hewett
cc. James G. Dolan, Jr., Planning Office of Urban. Affairs
Ellen F. Brawley, Landlord's Duty Authorized Agent
Shepard Brown, Niles Corporation
Better Business Bureau of Merrimack Valley
Charles Foster, No. Andover,,Building Inspector.
Everet. Tenney, No. Andover Health Department
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